Fellows-in-Training Newsletter

Spring 2002

The Gimmick Counter-Point Essay

Ram R Miller MD,CM FRCP(C)
Fellow Department of Medicine
Boston Medical Center

In an article written in this issue of the Fellows in Training Newsletter the issue was raised of "what is the niche of Geriatric Medicine." The article appears to express concern that as Geriatricians we lack a "gimmick" to set ourselves apart.

I feel we must first ask ourselves the question, "do we need a gimmick?"

One could certainly argue that the model of primary care Geriatrics does not need a gimmick. Primary care internists are "doctors for adults", so primary care geriatricians are doctors for older adults. General internists are never asked to justify their existence. With the rise of general internal medicine fellowships across the country they are often acquiring some subspecialty niches, but these are seen as a bonus, and not a shift in their focus of delivering primary care. Such a model could certainly work for geriatrics. We acquire additional skills that enable us to better care for elders, however the focus remains the delivery of primary care to this group. No gimmicks, primary care, plain and simple. To some extent those of us that opt to enter a one year fellowship are choosing this path.

However this is not the model to which others subscribe. There are many of us who elect to do two or more years of fellowship and develop highly subspecialized skills. But because there are two paths in geriatrics, we project two different faces to our colleagues in other branches of medicine. This may explain their occasional lack of understanding as to our role. On the one hand we want to be seen as deliverers of primary care, but on the other hand we want to be viewed as subspecialists. So to some extent we bear the blame for why some in other branches of medicine don't know what to make of us.

Other subspecialists, even those in "knowledge-based' subspecialties such as endocrinology and rheumatology, who also have no interventions to their name, don't have this problem of identity. They make no claim to being primary care physicians. As such, no one questions his or her "gimmicks." Although many of us feel comfortable handling diabetes and osteoarthritis we can all think of situations in which we were grateful to consult these subspecialists, and they return the patients to us thereafter with their recommendations. Perhaps if the endocrinologist were to claim primary care over all diabetics, and the rheumatologist were to claim the same over all of those with OA in addition to subspecialty care then general internists would raise the question of "what's the gimmick?" After all, we can all prescribe insulin, sulfonylureas and NSAIDs can't we?

Having done most of my medical training in Canada, where internists do not do primary care (family physicians do) I can say that for the most part geriatricians do function as subspecialists.

In the outpatient world geriatricians will do geriatric assessments on patients referred by family physicians, who value the ability of a geriatrician to help them with a complex patient, whether it be related to polypharmacy, functional decline, dementia or end of life issues. They will also run specialty multidisciplinary clinics dealing with dementia, incontinence and osteoporosis. In the hospital geriatrics wards function mostly along the geriatric rehabilitation model, where elders who need rehabilitation following a hospital stay may be sent. Geriatric consultations in hospital may deal with a variety of issues from geriatric assessment to acute delirium. In addition, geriatricians in certain institutions run outpatient geriatric rehabilitation centers called day hospitals, where elders may come following and acute event or on an ongoing basis to ensure maintenance of function in those at high risk.

So there are plenty of "gimmicks" for us to claim as geriatricians if we want to. If we go out and make a strong and clear claim to them, other physicians will realize that we can greatly assist them, as consultants, in the care of their patients. As individuals we have only to decide which of these "gimmicks" are right for us and as a group we need to continue to promote them.